Appropriate use criteria for transthoracic echocardiography at a tertiary care centerAppropriate use criteria for transthoracic echocardiography | Revista Portuguesa de Cardiologia (English edition)

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center”" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "719" "paginaFinal" => "722" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Comentário a critérios de adequação para ecocardiografia transtorácica num centro terciário" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2139 "Ancho" => 3257 "Tamanyo" => 847111 ] ] "descripcion" => array:1 [ "en" => "American College of Cardiology recommendations on the Choosing Wisely website.<a class="elsevierStyleCrossRef" href="#bib0265">23</a>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Galrinho" "autores" => array:1 [ 0 => 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=> array:1 [ 0 => array:2 [ "paginaInicial" => "713" "paginaFinal" => "718" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Paulo Fonseca, Francisco Sampaio, José Ribeiro, Helena Gonçalves, Vasco Gama" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Paulo" "apellidos" => "Fonseca" "email" => array:1 [ 0 => "paulobarbosafonseca@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Francisco" "apellidos" => "Sampaio" ] 2 => array:2 [ "nombre" => "José" "apellidos" => "Ribeiro" ] 3 => array:2 [ "nombre" => "Helena" "apellidos" => "Gonçalves" ] 4 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Critérios de adequação para ecocardiografia transtorácica num centro terciário" ] ] "textoCompleto" => "IntroductionOver the past decade, expenditure on cardiovascular imaging in general, and echocardiography in particular, have increased significantly,<a class="elsevierStyleCrossRef" href="#bib0085">1</a> which has raised concerns about the sustainability of this growth and potential overuse or misuse of imaging tests. In order to improve clinical practice, reduce unnecessary tests and enhance overall cost-effectiveness, the American College of Cardiology in partnership with the American Society of Echocardiography and other subspecialty societies developed appropriate use criteria (AUC) for transthoracic echocardiography (TTE). This document, first published in 2007<a class="elsevierStyleCrossRef" href="#bib0090">2</a> and updated in 2011,<a class="elsevierStyleCrossRef" href="#bib0095">3</a> contains recommendations for the rational use of TTE, rating the grade of appropriateness of various clinical indications. Since then, there have been studies of the appropriateness of clinical requests for TTE in different settings in the USA<a class="elsevierStyleCrossRefs" href="#bib0100">4–8</a> and Europe.<a class="elsevierStyleCrossRefs" href="#bib0125">9,10</a>The aim of this study was to assess whether TTE requests comply with the 2011 AUC at a Portuguese tertiary care center. In addition, we aimed to identify the factors associated with lower adherence to the AUC.MethodsStudy populationThe study included all TTE studies (in- and outpatient) performed over a period of one month (February 2014) at a non-university tertiary care center that provides health services to a population of 334000. We excluded from the analysis studies with insufficient clinical information to assign an indication and TTE performed for research purposes.Data collection and determination of indicationsPatient information was collected from request forms, medical records, previous TTE and other previous tests. The data on each patient were then analyzed by two independent imaging cardiologists, who matched each clinical scenario to a specific indication in the 2011 AUC document. If the reason for a TTE could be assigned to more than one indication, it was classified under the most appropriate indication. In patients who underwent more than one TTE study during the study period, each study was included independently in the analysis.Statistical analysisContinuous variables are described as means with standard deviation and categorical variables as frequencies and percentages. Comparisons were performed using the chi-square test using a p value of 0.05 for statistical significance. Analyses were performed using SPSS software (version 19.0, SPSS, Inc., Chicago, IL).ResultsGeneral characteristicsDuring the period under review, a total of 824 TTE studies were performed. We excluded twenty exams due to insufficient clinical information and five that were performed for research purposes. Overall, 799 exams were included in the analysis. The study population consisted of 784 patients, predominantly male (56.1%), with a mean age of 66.0±14.7 years. The majority were outpatients (75.1%). Most of the echocardiograms were requested by the cardiology department (52.1%), followed by internal medicine (21.7%), pneumology (8.9%), cardiothoracic surgery (6.6%), oncology (2.0%), neurology (1.9%) and nephrology (1.6%).Appropriateness of indicationsIn 97.5% of cases it was possible to determine an indication listed in the 2011 AUC. According to the AUC, 78.7% of the classifiable exams were appropriate, 15.3% inappropriate and 6.0% of uncertain appropriateness (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). <a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a> shows the distribution of TTE requests in major classes of indications and respective appropriateness. More than 80% of requested exams fell into one of the three following major classes: general evaluation of cardiac structure and function; evaluation of valvular function; and evaluation of hypertension, heart failure or cardiomyopathy.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The most common appropriate specific indication (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a>) was initial evaluation of patients with symptoms or conditions of suspected cardiac etiology (indication 1). Stroke or transient ischemic attack (TIA) (43.6%), chest pain (21.8%) and dyspnea (15.5%) were the main reasons for TTE performed under this indication. Other frequent appropriate indications were for initial evaluation of patients with known or suspected heart disease, including heart failure (indication 70), hypertensive heart disease (indication 67) and valvular or structural heart disease (indication 34).The main inappropriate indication, responsible for 61 (51.3%) of inappropriate exams, was routine surveillance of ventricular function in patients with known coronary artery disease (CAD) and no change in clinical status or cardiac exam (indication 11) (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 3</a>). Other frequent inappropriate indications were evaluation of patients with no symptoms or signs suggesting cardiac disease, either as screening (indication 10) or as perioperative evaluation (indication 13), responsible for 14 and 6 exams, respectively.<elsevierMultimedia ident="tbl0035"></elsevierMultimedia>Requests of uncertain appropriateness were mainly related to routine surveillance (≥1 year) of known cardiomyopathy without a change in clinical status (indication 89, 13 exams), initial evaluation for cardiac resynchronization therapy device optimization after implantation (indication 77, 12 exams) and routine surveillance (<1 year) of moderate or severe valvular regurgitation without a change in clinical status (indication 45, six exams).In- vs. outpatientsThe proportion of appropriate TTE was significantly higher among inpatients than in outpatients (93.0% vs. 74.2%, p<0.05) (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 4</a>). The most frequent appropriate indications for TTE in inpatients was evaluation of patients with conditions of suspected cardiac etiology, in particular stroke (indication 1) and evaluation of ventricular function following an acute coronary syndrome (indication 24), each responsible for 34 exams (16.6% of all inpatient studies). In outpatients, indication 1 was also the most frequent appropriate indication (12.8% of all outpatient studies), mainly due to dyspnea and chest pain. The most frequent inappropriate indication among inpatients was routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease (indication 13, four exams, 2.1% of all inpatient studies), while in outpatients it was routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam (indication 11, 61 exams, 10.3% of all outpatient studies).<elsevierMultimedia ident="tbl0045"></elsevierMultimedia>Cardiologists vs. non-cardiologistsCardiologists ordered inappropriate TTE more frequently than other specialties (19.3% vs. 10.9%, p<0.05). Our cardiology department is composed of 22 cardiology specialists, four of whom have an advanced echocardiography level and read TTE. Comparison of TTE readers with non-readers revealed no difference in rates of inappropriate requests (21.5% vs. 20.0%, p=0.81). Among cardiologists, 10.8% of exams were ordered by residents. Comparing cardiology residents with cardiology specialists showed a tendency for higher rates of inappropriate TTE in the residents (30.2% vs. 20.1%, p=0.13). The most frequent inappropriate indication was routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam (indication 11).In non-cardiology specialties, all TTE exams requested by oncologists and neurologists were appropriate. The sole indication for requesting an exam by oncologists was baseline and serial re-evaluations in patients undergoing therapy with cardiotoxic agents (indication 91), while neurologists requested TTE for evaluating patients with stroke or TIA (indication 1).Unclassifiable studiesTwenty exams were considered unclassifiable because they did not match any clinical indication listed in the AUC document. Exams performed after invasive procedures (pulmonary vein isolation or percutaneous closure of atrial septal defect or left atrial appendage) accounted for 50% of unclassifiable studies. Echocardiographic follow-up of patients who had undergone transcatheter aortic valve implantation (TAVI) was responsible for 35%. The other cases were for postoperative assessment of cardiac tumor resection (two cases) and repair of right ventricular perforation by a pacemaker lead (one case).DiscussionWe found that, according to the 2011 AUC document, 78.7% of TTE requests were appropriate, 15.3% were inappropriate and 6.0% were of uncertain appropriateness. These results are similar to those reported by other studies, in which appropriateness rates range from 71.0% to 96.5%.<a class="elsevierStyleCrossRefs" href="#bib0105">5,6,9,10</a> Several factors may influence these results, such as the setting in which the study is carried out (university vs. non-university center, tertiary vs. non-tertiary center, in- vs. outpatients), the characteristics of the study population and the specialty of the requesting physician.Given that in 2013 about 10 000 TTE exams were performed at our echocardiography laboratory (echo lab), the sample included in this study probably reflects the usual pattern of TTE requests at our center. A significant proportion of appropriate exams were performed to evaluate symptoms or conditions potentially related to cardiac etiology, in particular stroke or TIA. Other common appropriate indications were related to initial evaluation of patients with known or suspected heart failure, hypertensive heart disease or valvular or structural heart disease. A few scenarios account for the majority of inappropriate studies. The most significant was routine surveillance of ventricular function in patients with known CAD and no change in clinical status or cardiac exam, which is also reported in other studies as a frequent inappropriate indication.<a class="elsevierStyleCrossRefs" href="#bib0125">9,10</a>The study population was mainly composed of outpatients. We found that inappropriate requests were more frequent in outpatients than in inpatients. This is not unexpected, since inpatients commonly present new symptoms or signs suggesting cardiac disease or worsening of known cardiovascular disease, and both scenarios are rated as appropriate. On the other hand, outpatient requests usually refer to routine TTE in patients with no change in clinical status, which is normally rated as inappropriate. Previous studies have also reported a higher proportion of inappropriate exams among outpatients.<a class="elsevierStyleCrossRefs" href="#bib0100">4,5</a>Surprisingly, cardiologists presented a higher rate of inappropriateness (19.1%) than most other specialties. This was mainly related to routine evaluation of outpatients with known CAD and no change in clinical status. These findings conflict with other studies, in which cardiologists’ requests were more often appropriate than other specialties.<a class="elsevierStyleCrossRefs" href="#bib0125">9,10</a> At our center, cardiologists have close contact with the echo lab and easier access to the scheduling system than other specialties, which could explain some of the overuse of the technique. Interestingly, we found that cardiologists who read TTE had similar rates of inappropriate requests to other cardiologists.Cardiology residents presented a higher rate of inappropriate requests than cardiology specialists, although the difference was not statistically significant. Recently, Bhatia et al. reported similar rates of inappropriate TTE among cardiology fellows.<a class="elsevierStyleCrossRef" href="#bib0140">12</a>The Portuguese National Health Service provides health coverage for all the population and is mainly funded through general taxation. Physicians are paid a fixed monthly wage, which is not related to services rendered. Despite constant monitoring of effectiveness and quality, the national public health surveillance system does not perform any systematic monitoring of appropriateness of requested tests. The strict application of AUC would have reduced the number of exams performed annually at our echo lab by around 1500.There are few data on the best strategies to improve AUC compliance. Bhatia et al. reported a significant reduction in the proportion of inappropriate TTE exams in an inpatient academic medical service after implementation of a simple educational program consisting of lectures, pocket cards and feedback on ordering behavior via e-mail.<a class="elsevierStyleCrossRef" href="#bib0115">7</a> However, some methodological caveats have been pointed out regarding this study.<a class="elsevierStyleCrossRef" href="#bib0135">11</a> Recently, the same group of investigators reported the results of the first randomized control trial of an AUC-based educational and feedback intervention designed to reduce inappropriate outpatient TTE ordered by physicians-in-training, mainly cardiology fellows. After implementing an educational intervention (generally similar to that described above), they reported a significantly lower rate of inappropriate TTE in the intervention compared to the control group (13% vs. 34%, p<0.001).<a class="elsevierStyleCrossRef" href="#bib0140">12</a> Interestingly, in both in- and outpatient settings, there was an increase in inappropriate TTE during follow-up in the post-intervention period, suggesting the need for a continued program to achieve sustained improvement in physicians’ ordering behavior.<a class="elsevierStyleCrossRefs" href="#bib0140">12,13</a> Given the heterogeneity of most common inappropriate indications between centers, a strategy tailored to the specificities of each practice environment would be desirable.<a class="elsevierStyleCrossRef" href="#bib0115">7</a>Information on the clinical impact of AUC compliance is scarce and inconsistent. In a multicenter community study, Ballo et al. showed that TTE exams with appropriate or uncertain indications were often clinically more useful than those with inappropriate indications (87% vs. 14%, p<0.001).<a class="elsevierStyleCrossRef" href="#bib0125">9</a> Clinical impact was defined as any change in diagnostic workup, therapeutic decisions or follow-up planning induced by TTE results. However, more recently, in a single academic center study, Matulevicius et al., using the same definition, found a markedly lower overall rate of clinical impact (32%).<a class="elsevierStyleCrossRef" href="#bib0120">8</a> In addition, the proportion of exams resulting in an active change in clinical care did not correlate with AUC classification. However, the use of retrospective review of electronic medical records to determine clinical significance has been identified as a major drawback of this study.<a class="elsevierStyleCrossRef" href="#bib0150">14</a> One of the main challenges in future studies will be to define more precise measures of the utility of appropriate vs. inappropriate TTE in clinical practice.The 2011 update of the 2007 AUC increased the clinical indications for TTE from 59 to 98 and led to a significant reduction in unclassified studies.<a class="elsevierStyleCrossRefs" href="#bib0105">5,15</a> Indeed, in this study the AUC indications covered most of the clinical requests, with only 2.5% being unclassifiable. Control TTE after cardiovascular interventions and TAVI follow-up accounted for the majority of unclassifiable tests. Recently, the European Society of Cardiology and the European Association of Cardiovascular Imaging announced the formation of a taskforce to define appropriateness criteria for cardiovascular imaging use in clinical practice in Europe.<a class="elsevierStyleCrossRef" href="#bib0160">16</a> Some of these missing clinical scenarios should be considered in future recommendations.LimitationsThis is a single tertiary center study, and therefore the results cannot be extrapolated to other settings. Despite extensive review of all patient information, there was no direct contact with the ordering physician, and so the process of determining the AUC indication is not free of bias related to clinical factors not fully considered by the reviewers. We did not collect data on TTE abnormalities or assess its impact on decision-making due to the lack of detailed electronically stored information. Finally, we had a low number of TTE exams in an acute setting, since in this context cardiologists usually perform focused bedside echocardiography rather than complete TTE at the echo lab. This may result in some underestimation of the overall appropriateness of TTE, as in this group the rate of appropriateness is higher than in outpatients.ConclusionsThe majority of TTE requests at a Portuguese tertiary care center were appropriate. Cardiologists’ requests and outpatient referrals presented the highest rates of inappropriateness. Strategies to improve AUC compliance and evaluation of its impact on clinical outcomes should be explored in the near future.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." 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The objective of this study was to assess the rate of appropriate requests for transthoracic echocardiography at a Portuguese tertiary care center and to identify the factors associated with lower adherence to the appropriate use criteria. MethodsAll transthoracic echocardiograms (in- and outpatient) performed over a period of one month were analyzed by two independent imaging cardiologists, who matched each request to a specific indication in the appropriate use criteria document. ResultsOverall, 799 echocardiograms were included in the analysis. In 97.5% of cases it was possible to determine an indication listed in the criteria, according to which 78.7% of classifiable echocardiograms were appropriate, 15.3% inappropriate and 6.0% of uncertain appropriateness. The most common appropriate indication (111 echocardiograms) was initial evaluation of patients with symptoms or conditions potentially related to cardiac etiology, while the main inappropriate indication (59 echocardiograms) was routine surveillance of ventricular function in patients with known coronary artery disease and no change in clinical status or cardiac exam. The proportion of inappropriate echocardiograms was significantly higher among outpatients than among inpatients (18.8 vs. 4.3%, p<0.05) and among cardiologists compared to other specialties (19.3% vs. 10.9%, p<0.05). ConclusionsThe majority of requests for transthoracic echocardiograms at a Portuguese tertiary care center were appropriate. Requests by cardiologists and outpatient referrals presented the highest rates of inappropriateness." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosO American College of Cardiology e a American Society of Echocardiography desenvolveram critérios de utilização adequada da ecocardiografia. O objetivo deste estudo foi avaliar a taxa de pedidos apropriados de ecocardiograma transtorácico num centro terciário português e identificar os fatores associados à baixa adesão aos critérios de adequação. MétodosTodos os ecocardiogramas transtorácicos realizados durante um mês (internamento e ambulatório) foram analisados por dois cardiologistas independentes que estabeleceram a correspondência entre os pedidos e as indicações específicas dos critérios de adequação. ResultadosForam incluídos no estudo um total de 799 ecocardiogramas. Em 97,5% dos casos foi possível definir uma indicação específica. De acordo com os critérios de adequação, 78,7% dos ecocardiogramas classificáveis eram adequados, 15,3% inadequados e 6,0% de adequação incerta. A indicação adequada mais frequente (111 ecocardiogramas) foi a avaliação inicial de doentes com sintomas ou condições potencialmente relacionadas com etiologia cardíaca, enquanto a principal indicação inadequada (59 ecocardiogramas) foi a vigilância de rotina da função ventricular em doentes com doença coronária conhecida e sem alteração do seu estado clínico. A proporção de ecocardiogramas inadequados foi significativamente superior nos doentes de ambulatório comparativamente aos doentes internados (18,8 versus 4,3%, p < 0,05) e entre os cardiologistas comparativamente às restantes especialidades (19,3 versus 10,9%, p < 0,05). ConclusõesNum centro terciário português a maioria dos pedidos de ecocardiograma transtorácico foram apropriados. Os pedidos realizados por cardiologistas e em regime de ambulatório apresentaram as taxas mais elevadas de inadequação." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Appropriate \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inappropriate \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Uncertain \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">General evaluation of cardiac structure and function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">213 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">301 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular evaluation in an acute setting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of valvular function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">175 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">203 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of intracardiac and extracardiac structures and chambers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of aortic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of hypertension, heart failure or cardiomyopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">175 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adult congenital heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385225.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Major classes of indications according to appropriate use criteria category." ] ] 1 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ACS: acute coronary syndrome." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Appropriate indications</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n (% of appropriate) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Symptoms or conditions of suspected cardiac etiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">111 (18.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial evaluation of known or suspected heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (7.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial evaluation of suspected hypertensive heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (5.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial evaluation of ventricular function following ACS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (5.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial evaluation of suspected valvular or structural heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (4.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Evaluation of suspected pulmonary hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (4.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385224.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Most common appropriate indications." ] ] 2 => array:7 [ "identificador" => "tbl0035" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CAD: coronary artery disease." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Inappropriate indications</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n (% of inappropriate) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (51.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial evaluation of ventricular function (e.g., screening) with no symptoms or signs of cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Routine surveillance (<3 years after valve implantation) of prosthetic valve if no known or suspected valve dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385222.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Most frequent inappropriate indications." ] ] 3 => array:7 [ "identificador" => "tbl0045" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Appropriate, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inappropriate, n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Uncertain, n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">In- vs. outpatients</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inpatients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">174 (93.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Outpatients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">439 (74.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">111 (18.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (7.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Ordering specialty</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">291 (72.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 (19.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (8.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internal medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">149 (86.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (9.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (3.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pneumology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (85.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (12.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiothoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (90.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oncology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neurology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nephrology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (72.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (69.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (23.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385223.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Rates of appropriateness in different settings." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolving trends in the use of echocardiography: a study of Medicare beneficiaries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.S. 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Appropriate use criteria for transthoracic echocardiography at a tertiary care centerAppropriate use criteria for transthoracic echocardiography

Critérios de adequação para ecocardiografia transtorácica num centro terciário

Paulo Fonseca

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paulobarbosafonseca@hotmail.com

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, Francisco Sampaio, José Ribeiro, Helena Gonçalves, Vasco Gama

Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Over the past decade&#44; expenditure on cardiovascular imaging in general&#44; and echocardiography in particular&#44; have increased significantly&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> which has raised concerns about the sustainability of this growth and potential overuse or misuse of imaging tests&#46; In order to improve clinical practice&#44; reduce unnecessary tests and enhance overall cost-effectiveness&#44; the American College of Cardiology in partnership with the American Society of Echocardiography and other subspecialty societies developed appropriate use criteria &#40;AUC&#41; for transthoracic echocardiography &#40;TTE&#41;&#46; This document&#44; first published in 2007<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> and updated in 2011&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> contains recommendations for the rational use of TTE&#44; rating the grade of appropriateness of various clinical indications&#46; Since then&#44; there have been studies of the appropriateness of clinical requests for TTE in different settings in the USA<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#8211;8</span></a> and Europe&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study was to assess whether TTE requests comply with the 2011 AUC at a Portuguese tertiary care center&#46; In addition&#44; we aimed to identify the factors associated with lower adherence to the AUC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0015" class="elsevierStylePara elsevierViewall">The study included all TTE studies &#40;in- and outpatient&#41; performed over a period of one month &#40;February 2014&#41; at a non-university tertiary care center that provides health services to a population of 334<span class="elsevierStyleHsp" style=""></span>000&#46; We excluded from the analysis studies with insufficient clinical information to assign an indication and TTE performed for research purposes&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection and determination of indications</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patient information was collected from request forms&#44; medical records&#44; previous TTE and other previous tests&#46; The data on each patient were then analyzed by two independent imaging cardiologists&#44; who matched each clinical scenario to a specific indication in the 2011 AUC document&#46; If the reason for a TTE could be assigned to more than one indication&#44; it was classified under the most appropriate indication&#46; In patients who underwent more than one TTE study during the study period&#44; each study was included independently in the analysis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Continuous variables are described as means with standard deviation and categorical variables as frequencies and percentages&#46; Comparisons were performed using the chi-square test using a p value of 0&#46;05 for statistical significance&#46; Analyses were performed using SPSS software &#40;version 19&#46;0&#44; SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">General characteristics</span><p id="par0030" class="elsevierStylePara elsevierViewall">During the period under review&#44; a total of 824 TTE studies were performed&#46; We excluded twenty exams due to insufficient clinical information and five that were performed for research purposes&#46; Overall&#44; 799 exams were included in the analysis&#46; The study population consisted of 784 patients&#44; predominantly male &#40;56&#46;1&#37;&#41;&#44; with a mean age of 66&#46;0&#177;14&#46;7 years&#46; The majority were outpatients &#40;75&#46;1&#37;&#41;&#46; Most of the echocardiograms were requested by the cardiology department &#40;52&#46;1&#37;&#41;&#44; followed by internal medicine &#40;21&#46;7&#37;&#41;&#44; pneumology &#40;8&#46;9&#37;&#41;&#44; cardiothoracic surgery &#40;6&#46;6&#37;&#41;&#44; oncology &#40;2&#46;0&#37;&#41;&#44; neurology &#40;1&#46;9&#37;&#41; and nephrology &#40;1&#46;6&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Appropriateness of indications</span><p id="par0035" class="elsevierStylePara elsevierViewall">In 97&#46;5&#37; of cases it was possible to determine an indication listed in the 2011 AUC&#46; According to the AUC&#44; 78&#46;7&#37; of the classifiable exams were appropriate&#44; 15&#46;3&#37; inappropriate and 6&#46;0&#37; of uncertain appropriateness &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a> shows the distribution of TTE requests in major classes of indications and respective appropriateness&#46; More than 80&#37; of requested exams fell into one of the three following major classes&#58; general evaluation of cardiac structure and function&#59; evaluation of valvular function&#59; and evaluation of hypertension&#44; heart failure or cardiomyopathy&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The most common appropriate specific indication &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a>&#41; was initial evaluation of patients with symptoms or conditions of suspected cardiac etiology &#40;indication 1&#41;&#46; Stroke or transient ischemic attack &#40;TIA&#41; &#40;43&#46;6&#37;&#41;&#44; chest pain &#40;21&#46;8&#37;&#41; and dyspnea &#40;15&#46;5&#37;&#41; were the main reasons for TTE performed under this indication&#46; Other frequent appropriate indications were for initial evaluation of patients with known or suspected heart disease&#44; including heart failure &#40;indication 70&#41;&#44; hypertensive heart disease &#40;indication 67&#41; and valvular or structural heart disease &#40;indication 34&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main inappropriate indication&#44; responsible for 61 &#40;51&#46;3&#37;&#41; of inappropriate exams&#44; was routine surveillance of ventricular function in patients with known coronary artery disease &#40;CAD&#41; and no change in clinical status or cardiac exam &#40;indication 11&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 3</a>&#41;&#46; Other frequent inappropriate indications were evaluation of patients with no symptoms or signs suggesting cardiac disease&#44; either as screening &#40;indication 10&#41; or as perioperative evaluation &#40;indication 13&#41;&#44; responsible for 14 and 6 exams&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Requests of uncertain appropriateness were mainly related to routine surveillance &#40;&#8805;1 year&#41; of known cardiomyopathy without a change in clinical status &#40;indication 89&#44; 13 exams&#41;&#44; initial evaluation for cardiac resynchronization therapy device optimization after implantation &#40;indication 77&#44; 12 exams&#41; and routine surveillance &#40;&#60;1 year&#41; of moderate or severe valvular regurgitation without a change in clinical status &#40;indication 45&#44; six exams&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">In- vs&#46; outpatients</span><p id="par0055" class="elsevierStylePara elsevierViewall">The proportion of appropriate TTE was significantly higher among inpatients than in outpatients &#40;93&#46;0&#37; vs&#46; 74&#46;2&#37;&#44; p&#60;0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0045">Table 4</a>&#41;&#46; The most frequent appropriate indications for TTE in inpatients was evaluation of patients with conditions of suspected cardiac etiology&#44; in particular stroke &#40;indication 1&#41; and evaluation of ventricular function following an acute coronary syndrome &#40;indication 24&#41;&#44; each responsible for 34 exams &#40;16&#46;6&#37; of all inpatient studies&#41;&#46; In outpatients&#44; indication 1 was also the most frequent appropriate indication &#40;12&#46;8&#37; of all outpatient studies&#41;&#44; mainly due to dyspnea and chest pain&#46; The most frequent inappropriate indication among inpatients was routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease &#40;indication 13&#44; four exams&#44; 2&#46;1&#37; of all inpatient studies&#41;&#44; while in outpatients it was routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam &#40;indication 11&#44; 61 exams&#44; 10&#46;3&#37; of all outpatient studies&#41;&#46;</p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Cardiologists vs&#46; non-cardiologists</span><p id="par0060" class="elsevierStylePara elsevierViewall">Cardiologists ordered inappropriate TTE more frequently than other specialties &#40;19&#46;3&#37; vs&#46; 10&#46;9&#37;&#44; p&#60;0&#46;05&#41;&#46; Our cardiology department is composed of 22 cardiology specialists&#44; four of whom have an advanced echocardiography level and read TTE&#46; Comparison of TTE readers with non-readers revealed no difference in rates of inappropriate requests &#40;21&#46;5&#37; vs&#46; 20&#46;0&#37;&#44; p&#61;0&#46;81&#41;&#46; Among cardiologists&#44; 10&#46;8&#37; of exams were ordered by residents&#46; Comparing cardiology residents with cardiology specialists showed a tendency for higher rates of inappropriate TTE in the residents &#40;30&#46;2&#37; vs&#46; 20&#46;1&#37;&#44; p&#61;0&#46;13&#41;&#46; The most frequent inappropriate indication was routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam &#40;indication 11&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In non-cardiology specialties&#44; all TTE exams requested by oncologists and neurologists were appropriate&#46; The sole indication for requesting an exam by oncologists was baseline and serial re-evaluations in patients undergoing therapy with cardiotoxic agents &#40;indication 91&#41;&#44; while neurologists requested TTE for evaluating patients with stroke or TIA &#40;indication 1&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Unclassifiable studies</span><p id="par0070" class="elsevierStylePara elsevierViewall">Twenty exams were considered unclassifiable because they did not match any clinical indication listed in the AUC document&#46; Exams performed after invasive procedures &#40;pulmonary vein isolation or percutaneous closure of atrial septal defect or left atrial appendage&#41; accounted for 50&#37; of unclassifiable studies&#46; Echocardiographic follow-up of patients who had undergone transcatheter aortic valve implantation &#40;TAVI&#41; was responsible for 35&#37;&#46; The other cases were for postoperative assessment of cardiac tumor resection &#40;two cases&#41; and repair of right ventricular perforation by a pacemaker lead &#40;one case&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">We found that&#44; according to the 2011 AUC document&#44; 78&#46;7&#37; of TTE requests were appropriate&#44; 15&#46;3&#37; were inappropriate and 6&#46;0&#37; were of uncertain appropriateness&#46; These results are similar to those reported by other studies&#44; in which appropriateness rates range from 71&#46;0&#37; to 96&#46;5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#44;6&#44;9&#44;10</span></a> Several factors may influence these results&#44; such as the setting in which the study is carried out &#40;university vs&#46; non-university center&#44; tertiary vs&#46; non-tertiary center&#44; in- vs&#46; outpatients&#41;&#44; the characteristics of the study population and the specialty of the requesting physician&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that in 2013 about 10 000 TTE exams were performed at our echocardiography laboratory &#40;echo lab&#41;&#44; the sample included in this study probably reflects the usual pattern of TTE requests at our center&#46; A significant proportion of appropriate exams were performed to evaluate symptoms or conditions potentially related to cardiac etiology&#44; in particular stroke or TIA&#46; Other common appropriate indications were related to initial evaluation of patients with known or suspected heart failure&#44; hypertensive heart disease or valvular or structural heart disease&#46; A few scenarios account for the majority of inappropriate studies&#46; The most significant was routine surveillance of ventricular function in patients with known CAD and no change in clinical status or cardiac exam&#44; which is also reported in other studies as a frequent inappropriate indication&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The study population was mainly composed of outpatients&#46; We found that inappropriate requests were more frequent in outpatients than in inpatients&#46; This is not unexpected&#44; since inpatients commonly present new symptoms or signs suggesting cardiac disease or worsening of known cardiovascular disease&#44; and both scenarios are rated as appropriate&#46; On the other hand&#44; outpatient requests usually refer to routine TTE in patients with no change in clinical status&#44; which is normally rated as inappropriate&#46; Previous studies have also reported a higher proportion of inappropriate exams among outpatients&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Surprisingly&#44; cardiologists presented a higher rate of inappropriateness &#40;19&#46;1&#37;&#41; than most other specialties&#46; This was mainly related to routine evaluation of outpatients with known CAD and no change in clinical status&#46; These findings conflict with other studies&#44; in which cardiologists&#8217; requests were more often appropriate than other specialties&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9&#44;10</span></a> At our center&#44; cardiologists have close contact with the echo lab and easier access to the scheduling system than other specialties&#44; which could explain some of the overuse of the technique&#46; Interestingly&#44; we found that cardiologists who read TTE had similar rates of inappropriate requests to other cardiologists&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Cardiology residents presented a higher rate of inappropriate requests than cardiology specialists&#44; although the difference was not statistically significant&#46; Recently&#44; Bhatia et al&#46; reported similar rates of inappropriate TTE among cardiology fellows&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The Portuguese National Health Service provides health coverage for all the population and is mainly funded through general taxation&#46; Physicians are paid a fixed monthly wage&#44; which is not related to services rendered&#46; Despite constant monitoring of effectiveness and quality&#44; the national public health surveillance system does not perform any systematic monitoring of appropriateness of requested tests&#46; The strict application of AUC would have reduced the number of exams performed annually at our echo lab by around 1500&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">There are few data on the best strategies to improve AUC compliance&#46; Bhatia et al&#46; reported a significant reduction in the proportion of inappropriate TTE exams in an inpatient academic medical service after implementation of a simple educational program consisting of lectures&#44; pocket cards and feedback on ordering behavior via e-mail&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> However&#44; some methodological caveats have been pointed out regarding this study&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> Recently&#44; the same group of investigators reported the results of the first randomized control trial of an AUC-based educational and feedback intervention designed to reduce inappropriate outpatient TTE ordered by physicians-in-training&#44; mainly cardiology fellows&#46; After implementing an educational intervention &#40;generally similar to that described above&#41;&#44; they reported a significantly lower rate of inappropriate TTE in the intervention compared to the control group &#40;13&#37; vs&#46; 34&#37;&#44; p&#60;0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> Interestingly&#44; in both in- and outpatient settings&#44; there was an increase in inappropriate TTE during follow-up in the post-intervention period&#44; suggesting the need for a continued program to achieve sustained improvement in physicians&#8217; ordering behavior&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12&#44;13</span></a> Given the heterogeneity of most common inappropriate indications between centers&#44; a strategy tailored to the specificities of each practice environment would be desirable&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Information on the clinical impact of AUC compliance is scarce and inconsistent&#46; In a multicenter community study&#44; Ballo et al&#46; showed that TTE exams with appropriate or uncertain indications were often clinically more useful than those with inappropriate indications &#40;87&#37; vs&#46; 14&#37;&#44; p&#60;0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Clinical impact was defined as any change in diagnostic workup&#44; therapeutic decisions or follow-up planning induced by TTE results&#46; However&#44; more recently&#44; in a single academic center study&#44; Matulevicius et al&#46;&#44; using the same definition&#44; found a markedly lower overall rate of clinical impact &#40;32&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> In addition&#44; the proportion of exams resulting in an active change in clinical care did not correlate with AUC classification&#46; However&#44; the use of retrospective review of electronic medical records to determine clinical significance has been identified as a major drawback of this study&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> One of the main challenges in future studies will be to define more precise measures of the utility of appropriate vs&#46; inappropriate TTE in clinical practice&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The 2011 update of the 2007 AUC increased the clinical indications for TTE from 59 to 98 and led to a significant reduction in unclassified studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#44;15</span></a> Indeed&#44; in this study the AUC indications covered most of the clinical requests&#44; with only 2&#46;5&#37; being unclassifiable&#46; Control TTE after cardiovascular interventions and TAVI follow-up accounted for the majority of unclassifiable tests&#46; Recently&#44; the European Society of Cardiology and the European Association of Cardiovascular Imaging announced the formation of a taskforce to define appropriateness criteria for cardiovascular imaging use in clinical practice in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> Some of these missing clinical scenarios should be considered in future recommendations&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitations</span><p id="par0120" class="elsevierStylePara elsevierViewall">This is a single tertiary center study&#44; and therefore the results cannot be extrapolated to other settings&#46; Despite extensive review of all patient information&#44; there was no direct contact with the ordering physician&#44; and so the process of determining the AUC indication is not free of bias related to clinical factors not fully considered by the reviewers&#46; We did not collect data on TTE abnormalities or assess its impact on decision-making due to the lack of detailed electronically stored information&#46; Finally&#44; we had a low number of TTE exams in an acute setting&#44; since in this context cardiologists usually perform focused bedside echocardiography rather than complete TTE at the echo lab&#46; This may result in some underestimation of the overall appropriateness of TTE&#44; as in this group the rate of appropriateness is higher than in outpatients&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">The majority of TTE requests at a Portuguese tertiary care center were appropriate&#46; Cardiologists&#8217; requests and outpatient referrals presented the highest rates of inappropriateness&#46; Strategies to improve AUC compliance and evaluation of its impact on clinical outcomes should be explored in the near future&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ethical disclosures</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Protection of human and animal subjects</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Confidentiality of data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Right to privacy and informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Echocardiography"
            1 => "Transthoracic echocardiogram"
            2 => "Appropriate use criteria"
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            0 => "Ecocardiografia"
            1 => "Ecocardiograma transtor&#225;cico"
            2 => "Crit&#233;rios de utiliza&#231;&#227;o apropriada"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The American College of Cardiology and American Society of Echocardiography have developed appropriate use criteria for echocardiography&#46; The objective of this study was to assess the rate of appropriate requests for transthoracic echocardiography at a Portuguese tertiary care center and to identify the factors associated with lower adherence to the appropriate use criteria&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">All transthoracic echocardiograms &#40;in- and outpatient&#41; performed over a period of one month were analyzed by two independent imaging cardiologists&#44; who matched each request to a specific indication in the appropriate use criteria document&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Overall&#44; 799 echocardiograms were included in the analysis&#46; In 97&#46;5&#37; of cases it was possible to determine an indication listed in the criteria&#44; according to which 78&#46;7&#37; of classifiable echocardiograms were appropriate&#44; 15&#46;3&#37; inappropriate and 6&#46;0&#37; of uncertain appropriateness&#46; The most common appropriate indication &#40;111 echocardiograms&#41; was initial evaluation of patients with symptoms or conditions potentially related to cardiac etiology&#44; while the main inappropriate indication &#40;59 echocardiograms&#41; was routine surveillance of ventricular function in patients with known coronary artery disease and no change in clinical status or cardiac exam&#46; The proportion of inappropriate echocardiograms was significantly higher among outpatients than among inpatients &#40;18&#46;8 vs&#46; 4&#46;3&#37;&#44; p&#60;0&#46;05&#41; and among cardiologists compared to other specialties &#40;19&#46;3&#37; vs&#46; 10&#46;9&#37;&#44; p&#60;0&#46;05&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The majority of requests for transthoracic echocardiograms at a Portuguese tertiary care center were appropriate&#46; Requests by cardiologists and outpatient referrals presented the highest rates of inappropriateness&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">American College of Cardiology</span> e a <span class="elsevierStyleItalic">American Society of Echocardiography</span> desenvolveram crit&#233;rios de utiliza&#231;&#227;o adequada da ecocardiografia&#46; O objetivo deste estudo foi avaliar a taxa de pedidos apropriados de ecocardiograma transtor&#225;cico num centro terci&#225;rio portugu&#234;s e identificar os fatores associados &#224; baixa ades&#227;o aos crit&#233;rios de adequa&#231;&#227;o&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Todos os ecocardiogramas transtor&#225;cicos realizados durante um m&#234;s &#40;internamento e ambulat&#243;rio&#41; foram analisados por dois cardiologistas independentes que estabeleceram a correspond&#234;ncia entre os pedidos e as indica&#231;&#245;es espec&#237;ficas dos crit&#233;rios de adequa&#231;&#227;o&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram inclu&#237;dos no estudo um total de 799 ecocardiogramas&#46; Em 97&#44;5&#37; dos casos foi poss&#237;vel definir uma indica&#231;&#227;o espec&#237;fica&#46; De acordo com os crit&#233;rios de adequa&#231;&#227;o&#44; 78&#44;7&#37; dos ecocardiogramas classific&#225;veis eram adequados&#44; 15&#44;3&#37; inadequados e 6&#44;0&#37; de adequa&#231;&#227;o incerta&#46; A indica&#231;&#227;o adequada mais frequente &#40;111 ecocardiogramas&#41; foi a avalia&#231;&#227;o inicial de doentes com sintomas ou condi&#231;&#245;es potencialmente relacionadas com etiologia card&#237;aca&#44; enquanto a principal indica&#231;&#227;o inadequada &#40;59 ecocardiogramas&#41; foi a vigil&#226;ncia de rotina da fun&#231;&#227;o ventricular em doentes com doen&#231;a coron&#225;ria conhecida e sem altera&#231;&#227;o do seu estado cl&#237;nico&#46; A propor&#231;&#227;o de ecocardiogramas inadequados foi significativamente superior nos doentes de ambulat&#243;rio comparativamente aos doentes internados &#40;18&#44;8 <span class="elsevierStyleItalic">versus</span> 4&#44;3&#37;&#44; p &#60; 0&#44;05&#41; e entre os cardiologistas comparativamente &#224;s restantes especialidades &#40;19&#44;3 <span class="elsevierStyleItalic">versus</span> 10&#44;9&#37;&#44; p &#60; 0&#44;05&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Num centro terci&#225;rio portugu&#234;s a maioria dos pedidos de ecocardiograma transtor&#225;cico foram apropriados&#46; Os pedidos realizados por cardiologistas e em regime de ambulat&#243;rio apresentaram as taxas mais elevadas de inadequa&#231;&#227;o&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Appropriate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Inappropriate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Uncertain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">General evaluation of cardiac structure and function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">213&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">301&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular evaluation in an acute setting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of valvular function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">175&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">203&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of intracardiac and extracardiac structures and chambers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of aortic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluation of hypertension&#44; heart failure or cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">134&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">175&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adult congenital heart disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Appropriate indications</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37; of appropriate&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial evaluation of known or suspected heart failure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial evaluation of suspected hypertensive heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;5&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial evaluation of ventricular function following ACS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial evaluation of suspected valvular or structural heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;4&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evaluation of suspected pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Inappropriate indications</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37; of inappropriate&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Routine surveillance of ventricular function with known CAD and no change in clinical status or cardiac exam&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Routine surveillance &#40;&#60;3 years after valve implantation&#41; of prosthetic valve if no known or suspected valve dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Outpatients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">439 &#40;74&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">111 &#40;18&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;7&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;19&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;8&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Internal medicine&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;9&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pneumology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oncology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neurology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nephrology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;69&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;23&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Rates of appropriateness in different settings&#46;</p>"
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      "titulo" => "References"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evolving trends in the use of echocardiography&#58; a study of Medicare beneficiaries"
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                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;S&#46; Pearlman"
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                        "fecha" => "2007"
                        "volumen" => "49"
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              "identificador" => "bib0090"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ACCF&#47;ASE&#47;ACEP&#47;ASNC&#47;SCAI&#47;SCCT&#47;SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography"
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                        0 => array:2 [
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                          "autores" => array:3 [
                            0 => "P&#46;S&#46; Douglas"
                            1 => "B&#46; Khandheria"
                            2 => "R&#46;F&#46; Stainback"
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                      "doi" => "10.1016/j.jacc.2007.05.003"
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                      "doi" => "10.1016/j.jacc.2010.11.002"
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                      "titulo" => "Evaluation of appropriate use of transthoracic echocardiography in 1820 consecutive patients using the 2011 revised appropriate use criteria for echocardiography"
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                      "doi" => "10.1016/j.amjcard.2012.02.025"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.12.004

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Year/Month	Html	Pdf	Total

2024 November	6	4	10
2024 October	31	28	59
2024 September	49	25	74
2024 August	43	26	69
2024 July	31	27	58
2024 June	23	35	58
2024 May	43	31	74
2024 April	29	34	63
2024 March	26	15	41
2024 February	26	16	42
2024 January	22	25	47
2023 December	16	26	42
2023 November	35	22	57
2023 October	32	14	46
2023 September	20	19	39
2023 August	22	10	32
2023 July	32	11	43
2023 June	33	17	50
2023 May	32	29	61
2023 April	19	2	21
2023 March	31	19	50
2023 February	20	19	39
2023 January	30	16	46
2022 December	21	14	35
2022 November	30	32	62
2022 October	32	13	45
2022 September	26	22	48
2022 August	28	29	57
2022 July	34	40	74
2022 June	22	16	38
2022 May	26	28	54
2022 April	30	20	50
2022 March	20	33	53
2022 February	20	27	47
2022 January	18	22	40
2021 December	22	27	49
2021 November	27	32	59
2021 October	22	38	60
2021 September	25	28	53
2021 August	26	31	57
2021 July	19	26	45
2021 June	21	13	34
2021 May	31	35	66
2021 April	43	38	81
2021 March	43	14	57
2021 February	60	21	81
2021 January	28	12	40
2020 December	38	7	45
2020 November	27	19	46
2020 October	21	16	37
2020 September	44	9	53
2020 August	20	10	30
2020 July	41	11	52
2020 June	26	9	35
2020 May	35	5	40
2020 April	41	9	50
2020 March	38	9	47
2020 February	32	16	48
2020 January	22	8	30
2019 December	33	3	36
2019 November	26	6	32
2019 October	13	7	20
2019 September	26	11	37
2019 August	14	2	16
2019 July	41	6	47
2019 June	16	18	34
2019 May	37	10	47
2019 April	19	8	27
2019 March	16	8	24
2019 February	26	11	37
2019 January	19	7	26
2018 December	35	8	43
2018 November	88	19	107
2018 October	136	25	161
2018 September	34	13	47
2018 August	33	5	38
2018 July	20	3	23
2018 June	31	6	37
2018 May	48	4	52
2018 April	50	2	52
2018 March	47	6	53
2018 February	60	11	71
2018 January	11	4	15
2017 December	80	9	89
2017 November	24	10	34
2017 October	25	7	32
2017 September	22	10	32
2017 August	25	7	32
2017 July	24	9	33
2017 June	29	7	36
2017 May	20	7	27
2017 April	23	12	35
2017 March	33	40	73
2017 February	20	3	23
2017 January	16	2	18
2016 December	32	8	40
2016 November	20	5	25
2016 October	31	2	33
2016 September	10	4	14
2016 August	10	0	10
2016 July	10	4	14
2016 June	8	5	13
2016 May	11	2	13
2016 April	12	8	20
2016 March	18	13	31
2016 February	29	32	61
2016 January	34	9	43

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